QI

EMSI Regional QI/QA Initiative

An EMS agency shall have a safety committee and a quality improvement committee that meet at least quarterly. If an EMS agency operates an EMS agency dispatch center, the quality improvement committee shall also be responsible for the quality improvement of the EMS agency dispatch center and participate in the county PSAP quality assurance process.

Note: Projects will count as regional QI Initiatives for all participating EMS agencies.

§ 1021.61. Components of Statewide quality improvement program.

(a) The Department, in conjunction with the Advisory Board, will identify the necessary components for a Statewide EMS quality improvement program for the Statewide EMS system. The Statewide EMS quality improvement program shall be operated to monitor the delivery of EMS.

(b) The Department will develop and update a Statewide EMS Quality Improvement Plan in which it will establish goals and reporting thresholds.

§ 1021.62. Regional quality improvement programs.

A regional EMS council, after considering input from participants in and persons served by the regional EMS system, shall develop, update and implement a regional EMS quality improvement program to monitor the delivery of EMS, which addresses, at a minimum, the quality improvement components identified by the Department. A regional EMS council quality improvement program shall:

(1) Conduct quality improvement audits of the regional EMS system including reviewing the quality improvement activities conducted by the EMS agency medical directors and medical command facilities within the region.

(2) Have a regional quality improvement committee that, in conjunction with the regional medical advisory committee, shall recommend to the regional EMS council ways to improve the delivery of EMS within the region based upon State and regional goals.

(3) Develop and implement a regional EMS quality improvement plan to assess the EMS system in the region.

(4) Investigate complaints concerning the quality of care rendered and forward recommendations and findings to the Department.

§ 1021.63. Peer review.

(b) Purpose. The purpose of peer review conducted under this section is to evaluate the quality and efficiency of services performed under this part by EMS providers, EMS agency medical directors and medical command physicians. This includes reviews to:

(1) Evaluate and improve the quality of EMS rendered.

(2) Determine whether the direction and supervision of EMS providers was in accordance with accepted standards.

(3) Determine whether the EMS provided or not provided was in accordance with accepted standards of care.

(c) Composition of peer review committee. A peer review committee established under this section may include health care providers such as EMS providers, EMS agency medical directors and other physicians, nurses, physician assistants, EMS agency managers and administrators, hospital personnel with expertise in quality assurance and PSAP dispatchers and administrators.

(d) Proceedings and records of a peer review committee. The proceedings and records of a peer review committee conducted under this section have the same protections from discovery and introduction into evidence in civil proceedings as they would under the Peer Review Protection Act (63 P. S. §§ 425.1—425.4). A person who attends a meeting of a peer review committee has the same right as a person who attends a meeting of a review organization under the Peer Review Protection Act with respect to not testifying in a civil action as to evidence or other matters produced or presented during the peer review proceeding or as to findings, recommendations, evaluations, opinions or other actions of the peer review committee or other records thereof. These protections do not apply to records that are reviewed in peer review, but were not created for the sole purpose of being reviewed in a peer review proceeding. A person who testifies before a peer review committee or who is a member of a peer review committee is not protected from testifying as to matters within that person's knowledge, except as to that person's testimony before the peer review committee, matters learned by that person through that person's participation in the peer review committee's proceeding or opinions formed by that person as a result of the peer review proceeding.

(e) Persons who provide information to a peer review committee. A person who provides information to a peer review committee conducting peer review under this section has the same protections from civil and criminal liability as a person who provides information to a review organization under the Peer Review Protection Act.

(f) Members and employees of a peer review committee and persons who furnish professional services to a peer review committee. An individual who is a member or employee of a peer review committee or who provides professional services to a peer review committee conducting peer review under this section has the same protections from civil and criminal liability for the performance of any duty, function or activity required of the peer review committee as a person who performs the duty, function or activity under the Peer Review Protection Act.

§ 1021.64. Cooperation.

Each individual and entity licensed, certified, recognized, accredited or otherwise authorized by the Department to participate in the Statewide EMS system shall cooperate in the Statewide and regional EMS quality improvement programs and peer reviews conducted under the act and this subchapter and shall provide information, data, reports and access to records, including audio records, as reasonably requested by quality improvement and peer review committees to conduct reviews.